After the death of the nation's first Ebola patient diagnosed in the US and subsequent infection of two Texas nurses who cared for the patient, the protocol was under great scrutiny. Although many teams have investigated the chain of events leading to the 2 nurses' contracting the virus, the specific problem leading to the exposures may never be known.

On Monday evening, October 20, the US Centers for Disease Control (CDC) unveiled new PPE recommendations for healthcare workers who will be dealing with Ebola patients. The new guidelines reflect the protocol practiced in Emory University Hospital, Nebraska Medical Center, and the National Institutes of Health Clinical Center. The new guidelines focus on specific personal protective equipment for health care workers and "offers detailed step by step instructions for how to put the equipment on and take it off safely." While the main change is no exposed skin, there are two options for respiratory protection.

At a media telebriefing, CDC Director Tom Frieden said of the initial Ebola recommendations released on August 1, 2014:

"The bottom line is that the recommendations didn't work for that hospital,"

"[T]he new PPE recommendations are designed to increase the margin of safety for frontline health workers and reflect an expert consensus."

The enhanced guidance is centered on three principles:

All healthcare workers undergo rigorous training and are practiced and competent with PPE, including taking it on and off in a systemic manner

No skin exposure when PPE is worn

All workers are supervised by a trained monitor who watches each worker taking PPE on and off.

Principle #1: Rigorous and repeated training

Focusing only on PPE gives a false sense of security of safe care and worker safety. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step donning and doffing of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.

Principle #2: No skin exposure when PPE is worn

Given the intensive and invasive care that US hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn.

CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods. Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single use disposable full face shield. Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands. PPE recommended for U.S. healthcare workers caring for patients with Ebola includes:

Double gloves

Boot covers that are waterproof and go to at least mid-calf or leg covers

Single use fluid resistant or imperable gown that extends to at least mid-calf or coverall without intergraded hood.

Respirators, including either N95 respirators or powered air purifying respirator(PAPR)

Single-use, full-face shield that is disposable

Surgical hoods to ensure complete coverage of the head and neck

Apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea

The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel.

Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE.

Principle #3: Trained monitor

CDC is recommending a trained monitor actively observe and supervise each worker taking PPE on and off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address.

PPE is Only One Aspect of Infection Control

It is critical to focus on other prevention activities to halt the spread of Ebola in healthcare settings, including:

Prompt screening and triage of potential patients

Designated site managers to ensure proper implementation of precautions

Limiting personnel in the isolation room

Effective environmental cleaning

Think Ebola and Care Carefully

The CDC reminds health care workers to "Think Ebola" and to "Care Carefully." Health care workers should take a detailed travel and exposure history with patients who exhibit fever, severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, unexplained hemorrhage. If the patient is under investigation for Ebola, health care workers should activate the hospital preparedness plan for Ebola, isolate the patient in a separate room with a private bathroom, and to ensure standardized protocols are in place for PPE use and disposal. Health care workers should not have physical contact with the patient without putting on appropriate PPE.

CDC's Guidance for U.S. Healthcare Settings is Similar to MSF's (Doctors Without Borders) Guidance

Both CDC's and MSF's guidance focuses on:

Protecting skin and mucous membranes from all exposures to blood and body fluids during patient care

Meticulous, systematic strategy for putting on and taking off PPE to avoid contamination and to ensure correct usage of PPE

Use of oversight and observers to ensure processes are followed

Disinfection of PPE prior to taking off: CDC recommends disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment. Additionally, CDC recommends disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE. Due to differences in the U.S. healthcare system and West African healthcare settings, MSF's guidance recommends spraying as a method for PPE disinfection rather than disinfectant wipes.

Five Pillars of Safety

CDC reminds all employers and healthcare workers that PPE is only one aspect of infection control and providing safe care to patients with Ebola. Other aspects include five pillars of safety:

Facility leadership has responsibility to provide resources and support for implementation of effective prevention precautions. Management should maintain a culture of worker safety in which appropriate PPE is available and correctly maintained, and workers are provided with appropriate training.

Designated on-site Ebola site manager responsible for oversight of implementing precautions for healthcare personnel and patient safety in the healthcare facility.

Clear, standardized procedures where facilities choose one of two options and have a back-up plan in case supplies are not available.

Trained healthcare personnel: facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment.

Oversight of practices are critical to ensuring that implementation protocols are done accurately, and any error in putting on or taking off PPE is identified in real-time, corrected and addressed, in case potential exposure occurred.

We are utilizing the CDC "recommendations" and going way beyond them to protect our staff. As one who has been training them, I can tell you there are still a lot of unanswered questions, and it's scary knowing that we have to be at the ready....and then recommendations may be changed again!

We are utilizing the CDC "recommendations" and going way beyond them to protect our staff. As one who has been training them, I can tell you there are still a lot of unanswered questions, and it's scary knowing that we have to be at the ready....and then recommendations may be changed again!

This is the hard part. My facility has had 3 plans already, each time having to change due to CDC guidlines.

I do like the fact of having a trained observer watching the donning and doffing. Helps to watch and remind correct procedure since that it their only job.

Oct 21, '14

The previous CDC guidelines left me wondering what in the world they were thinking. Well, it seems THIS is what they were thinking:

"Dr. Fauci said the C.D.C.′s old guidelines had been based on those issued by the World Health Organization and were meant for use “in the field, in the bush” rather than in a modern hospital." Okayyyyy...?

Have read the above mentioned precautions, noticed that there was mention of an isolation room with own bathroom, have anyone at CDC realized that human waste such as urine and feces are also sources of contamination so wherever waste from these bathrooms are disposed of may be or are definite source of contamination that escapes the quarantined area. Please take note of proper waste disposal and handling of contaminated PPE and every form of waste body fluids of contaminated patients to avoid further contamination outbreak.

Oct 21, '14

Also i hope that I don't offend anybody, but the worst that their respective governments have done was to bring home their contaminated health care workers. we all know that they are capable of bringing in all the necessary supplies and medication into the affected nations in africa and have their own health workers treated there until their conditions stabilized, thereby reducing the risks of causing outbreaks or contamination into their respective countries which brought fear to their citizenry. If they have experimental drugs who are the right people to first test them out but the people already suffering from the virus.

Oct 21, '14

Finally - some guidelines I feel relatively safe following! Now our hospital will provide the same equipment we have seen used in the news. Why did it take so long for the CDC to reach this conclusion? Doesn't seem that hard to figure out. We nurses knew all along we wanted to be securely and completely covered head to toe!

Oct 21, '14

Why did it take so long for the CDC to reach this conclusion?

I'm just as confused as you are. The CDC cannot possibly be that ignorant. It's not possible. It doesn't make any sense, no sense at all. Their own guidelines for lab workers dealing with Ebola call for full biosafety level 4 precautions, including positive-pressure, air-supplied suits. But nurses and other HCWs were supposed to be protected by simple droplet precautions? I wish someone would ask these questions, and demand a real answer.

Oct 21, '14

So glad to see at least someone at the CDC removing their head from their behind. My hospital is probably getting sick of giving ever changing ebola inservices (none of which I've been there for, and all of which have only been held once). At least this protocol seems more protective.

Oct 21, '14

None of us work at a level 4 biocontainment facility. (I'm assuming) None of us should be caring for an Ebola patient unless we work in one of those. We have been "shown" how to don and doff, but have not been allowed to practice due to cost of the suits. So no thank you, I won't care for anyone with Ebola in an ill-prepared hospital. They can realize their inadequacies with another nurse, not me.

Oct 21, '14

Below are handouts from University of Nebraska Medical Center. One is for donning PPE and the other doffing. Very informative and educational.

In theory, I wish I could put my trust in the CDC...and/or the hospital. In reality, when I think about the possibility of bringing this disease home to my family, I don't know if there is enough PPE in the Western Hemisphere...not after the amount of conflicting information I've heard. You nurses on the "front lines" in Texas, et al., I salute you. I pray for your continued health, and I thank you.

Oct 21, '14

National Nurses Statement on New CDC Ebola Guidelines

Oct. 21, 2014 — /PRNewswire/ -- National Nurses United today welcomed the call in the latest guidelines from the Centers for Disease Control and Prevention for "rigorous and repeated training" for nurses and other health workers responding to the Ebola virus as NNU has been urging for two months, but said some substantial questions and concerns remain.

"It is clear from the abrupt change in position of the CDC in some areas that the registered nurses have moved the country and the CDC as the nurses champion protection for their patients and articulate the vulnerabilities for themselves.

Nevertheless, the optimal standards should be in place tomorrow and, regrettably, they will not be," said NNU Executive Director RoseAnn DeMoro.

With still significant questions regarding the most effective personal protective equipment, and the ongoing lack of any mandate on the hospitals to comply with the highest standards and protocols, "it is clear that nurses are going to have to continue to fight every step of the way to demand that every patient, every nurse, every frontline healthcare worker has the protection they need," DeMoro said.

"The governing theme must be the precautionary principle, the highest safety standards in the face of this virulent disease, so that no nurses, other frontline health workers, or patients have to put their lives in jeopardy," DeMoro said.

DeMoro noted that the call for continuous training, especially in group sessions with everyone practicing putting on and taking off the protective equipment, echoes a key demand of nurses...

... Second, DeMoro called the guideline that any protective equipment leave 'no skin exposed,' a "direct testament to the courage of Briana Aguirre," the Texas Presbyterian Hospital RN who "made the incredibly brave decision" to publicly disclose that the suits at her Dallas hospital left exposed the necks and other skin of nurses who cared for Ebola-infected patients.

"Briana will be remembered as the Karen Silkwood of our time," DeMoro said. The gap in the suits was also revealed in a statement from Aguirre and other Dallas RNs released by NNU last week.

However, the CDC guidelines remain unclear on the most effective protective equipment, and, significantly, have their own gaping hole in the option offered to hospitals to select which protective equipment to use "based on availability" and other factors.

DeMoro called that loophole "an open invitation for hospitals to choose the cheapest protective equipment that will continue to put nurses and other health workers at considerable risk. Years of experience with our private hospital industry have demonstrated that far too many hospitals routinely put their budget goals and profit margins ahead of public safety, including in access to protective equipment."

"We are contacting the CDC for specifics on the proper protective equipment and whether it meets the precautionary principle and the highest standard, in particular, full body coverage that prevents any blood or viral penetration," DeMoro said.

Finally, she noted, "CDC readily admits it is not a regulatory agency. It has no authority to compel hospitals to comply with any guidelines."

"That is why we will continue to insist that Congress and the White House should mandate all hospitals meet the optimal uniform, national standards and protocols in order to safely protect patients, all healthcare workers and the public," DeMoro said.